Cognitive-Behavioral Approaches to Alcoholism Treatment.

Cognitive-behavioral theories explain alcoholism as a learned behavior that can be changed using the same behavior modification interventions employed to alter other learned behaviors. Treatment interventions teach clients the skills they need to confront or avoid everyday situations that may lead to drinking.

1 Terms such as "alcoholism" and "alcohol depend ence" are understood in this article as referring to criteria for alcohol dependence and abuse in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Pathological drinking refers to the entire range of alcohol problems from mild to severe.
These and other related methods are described in this article, along with con siderations of their effectiveness.

OVERVIEW OF THE COGNITIVE BEHAVIORAL THEORY
Cognitivebehavioral theory views alco hol dependence as a maladaptive means of coping with problems (e.g., social problems) or meeting certain needs. From this point of view, alcoholic drinking is a sequence of learned behaviors acquired in the same manner as any other learned behaviors: through imitating role models, as a result of experiencing the positive effects of alcohol (e.g., reducing anxiety, relieving pain, or enhancing sociability), or based on expectations that alcohol will have one or more of these effects (Monti et al. 1989). After repeated positive expe riences with alcohol, some individuals begin to rely on alcohol consumption as the preferred way of coping with prob lems or meeting needs, especially because alcohol's effects are felt fairly rapidly and require relatively little effort on the part of the drinker. According to cognitive RONALD M. KADDEN, PH.D., is a professor in the Department of Psychiatry, University of Connecticut School of Medicine, Farmington, Connecticut.
behavioral theory, these learned drinking patterns can be altered through the appli cation of combined cognitive and behav ior modification interventions, which can help people with alcohol dependence achieve and maintain sobriety .
In addition to the view of alcoholism as a learned phenomenon, other theories have been developed to account for its origins. One of these focuses on genetics as a factor in the development of alcohol dependence. Even from this perspective, however, the way in which a genetic vulnerability is expressed is dependent upon a person's psychosocial experiences (Tarter and Vanyukov 1994). As a result, whatever drinking patterns are acquired ought to be amenable to remediation by cognitivebehavioral interventions (Monti et al. 1989).

Antecedents of Drinking Alcohol
The cognitivebehavioral approach to alcoholism treatment focuses on the factors that precipitate and sustain drinking. Antecedents are the events that occur prior to drinking and either set the occa sion for it or initiate a chain of behaviors that culminates in drinking. Different types of antecedent factors may lead to a per son's drinking (Miller and Mastria 1977). They can be social, such as interpersonal  C o g n i t i v e b e h a v i o r a l t r e a t m e n t a d d r e s s e s t h e s e e v e n t s t h a t o c c u r a f t e r d r i n k i n g . I t i n v o l v e s a r r a n g i n g a l t e r n a t i v e , l e s s d e s i r a b l e c o n s e q u e n c e s f o r d r i n k i n g ( e . g . , a s i g n i f i c a n t o t h e r w i t h d r a w i n g f r o m s o c i a l i n t e r a c t i o n s w i t h t h e d r i n k e r ) a n d a r r a n g i n g p o s i t i v e c o n s e q u e n c e s f o r s o b r i e t y ( e . g . , a s i g n i f i c a n t o t h e r p r o v i d i n g a t t e n t i o n a n d r e c o g n i t i o n ) . t r e s s m a n a g e m e n t t r a i n i n g , a t r e a t m e n t c o m p o n e n t t h a t c a n i n c l u d e r e l a x a t i o n t r a i n i n g ( e . g . , u s i n g s l o w b r e a t h i n g t o r e l a x a n d c o n t r o l a n x i e t y ) , s y s t e m a t i c d e s e n s i t i z a t i o n ( e . g . , l e a r n i n g t o t o l e r a t e f e a r e d s i t u a t i o n s t h r o u g h g r a d u a l e x p o s u r e t o t h e m ) , a n d c o g n i t i v e s t r a t e g i e s ( e . g . , c o r r e c t i n g n e g a t i v e i n t e r p r e t a t i o n s o f e v e n t s ) ( S t o c k w e l l a n d T o w n 1 9 8 9 ) . O t h e r i n t r a p e r s o n a l s k i l l s t h a t m a y b e t a u g h t i n c l u d e c o p i n g w i t h a n g e r o r w i t h n e g a t i v e t h o u g h t s ( s e e K a d d e n e t a l . Therapists also may have to help their clients fill the leisure time they gain when they stop drinking. Unless free time is used appropriately, it could lead to bore dom and attendant cravings for alcohol or to activities that increase the chances of drinking. Thus, clients should sample various leisure activities to find those that they enjoy, that are incompatible with drinking, and that also could be used from time to time as rewards for specific ac complishments along the road to sobriety.

Behavioral Deficits That Impede Treatment
Finally, it is unlikely that therapists will be able to identify all the factors relevant to a client's drinking or anticipate all possible highrisk situations. Therefore, each client should develop a set of emer gency plans for confronting any unfore seen situations that may arise. These plans usually include coping skills developed over the course of treatment, such as man aging thoughts about alcohol, developing problemsolving skills, and telephoning people in one's social support network. In addition, clients need to formulate plans for coping with persistent problems that cannot be resolved and are likely to present continuing challenges to sobriety.
Interpersonal Skills. In many cases, the therapist's functional analysis of the client's drinking behaviors identifies problems encountered in interactions with others. Consequently, clients have to learn to resist offers to drink or related forms of social pressure from coworkers, friends, or even family members. In addition, clients may be deficient in very basic social skills, leaving them isolated and without adequate social support, which are com mon antecedents to drinking. These clients benefit from training in starting conversa tions, nonverbal communication (body language), giving compliments, being assertive, refusing requests to do things for others that will overburden them, commu nicating emotions, and improving func tioning in an intimate relationship. Clients also can learn to handle criticism so that neither giving it nor receiving it will arouse strong negative emotions that could lead to a relapse. Finally, training may be necessary in the development and nurtu rance of a social support network, which would enhance the likelihood of their maintaining sobriety.

Training Influences
The cognitivebehavioral approach con cerns not only the content of therapy but also the manner in which it is delivered (Monti et al. 1989). Verbal descriptions of new skills are kept to a minimum, with the therapist placing greater emphasis on modeling the skills and on active practice by clients. Practice should include a wide variety of roleplay scenarios to broaden the skills' applicability. Likewise, home work assignments may be given to foster use of the skills in reallife situations. Frequent reviews of previously taught skills will enhance the clients' mastery and help to counter problems they may have in retaining the skills.

Sequence of Skills Training.
Although good pedagogy suggests that learning should proceed from the simplest skills to the more complex, some treatment situa tions require that therapists first provide training in complex skills, which are essential for abstinence, to prevent relapse and early dropout from treatment. Clients who live at home and receive outpatient treatment, for example, are likely to encounter highrisk situations daily that require complex skills. It often is neces sary for therapists to teach their clients how to manage their anger or how to manage their thoughts about drinking prior to teaching more basic skills, such as starting conversations or nonverbal communication.

Influence of the Treatment Setting.
Methods of cognitivebehavioral skills training also may be influenced by whether therapy takes place in an individual or group context. In coping skills training, group therapy provides a convenient set ting for skills modeling, rehearsal, and feedback, and it allows clients to share experiences they have had using the skills that they are being taught. Individual therapy provides greater attention to peo ple for whom group therapy may not be recommended (indications for individual therapy are reviewed by Rounsaville and Carroll 1992). In this case, the therapist assumes functions usually assigned to group members. Organized inpatient and partial hospi tal treatment programs may use systems of rewards and penalties, called contin gency management techniques, to re inforce appropriate client behaviors. Such appropriate behaviors can include partici pating in treatment activities, practicing skills, and planning for continued care after discharge from the program. Con tingency management may be useful particularly for clients who are impulsive, who require structure, or who may be poorly motivated.
Clients who participate in inpatient and partial hospital treatment programs receive a list of routines and rules that specify consequences for infractions and rewards for appropriate behaviors or successful completion of program goals. Clients may select rewards from options ordinarily available in the program envi ronment, such as freedom to move about the facility unescorted, offgrounds pass es, unlimited telephone privileges, gifts of literature from Alcoholics Anonymous, and a certificate upon completion of treatment. Negative consequences for infractions of rules may entail a loss of certain privileges (for further detail, see Kadden and Mauriello 1991).

RELAPSE PREVENTION
This approach to treatment is similar to coping skills training and employs many of its methods. Relapse prevention, however, has fostered a closer analysis of the relapse process, focusing on interventions that may be used to interrupt it and identifying Does not use adequate coping response.
Experiences a sense of helplessness or passivity and decreased self-control.
Has expectation that a drink would help the situation (positive outcome expectancies).
These perceptions and expectancies lead to initial use of alcohol.
Chooses and makes use of appropriate coping response.
Experiences a sense of mastery and an ability to cope with the situation.
These perceptions decrease the likelihood of a relapse.

Figure 1
Confronts a high-risk situation.

Client
Results in "abstinence violation effect," wherein client contrasts previous selfperception of being in recovery with present reality.
Feels guilt and loss of control.
These feelings increase the probability of a relapse.
behaviors that should be strengthened to maintain longterm sobriety. Figure 1 provides Marlatt's (1985) schematic of the relapse process, depict ing two possible responses to a highrisk situation. As shown, when clients choose and execute an appropriate coping re sponse, they feel a sense of mastery, but when no coping response is used, they feel helpless and anticipate that a drink would help in the situation. Such thoughts are likely to be followed by drinking, and the clients then contrast the previous perception of being in recovery with the current reality of renewed drinking. This incongruity leads to feelings of conflict, guilt, selfblame, and perceived loss of control, a syndrome that Marlatt has called the "abstinence violation effect." Because of this despair, further drinking becomes likely and often leads to a fullblown relapse (Marlatt 1985).
The therapist may use several of the following interventions to help clients avoid highrisk situations (Marlatt and Gordon 1985): • Modifying clients' lifestyles by strengthening behaviors that are in compatible with drinking • Providing training in decisionmaking and selfcontrol that enables clients to make appropriate choices • Establishing a balance between the time clients spend meeting responsibil ities and the time spent on pleasurable activities.
Central to this approach is the en hancement of clients' awareness of highrisk situations when they are at an early stage, during which the situations do not appear overwhelming and therefore are easiest to manage. Therapists teach clients to monitor and evaluate their feelings, their thoughts, and the situations in which they find themselves to identify potential antecedents to drinking. Suc cessful coping with these antecedents requires that clients acquire skills for managing external triggers, handling their emotions, and countering cognitive distortions about themselves.
Clients' expectancies regarding the positive effects of alcohol can be combated if the therapist educates the clients about the delayed negative effects of drinking and suggests that they carry a reminder card listing the negative effects they have experienced. Clients may be taught to view a slip (e.g., taking a drink) as a learning experience and an opportunity to formulate more effective plans for coping with simi lar situations in the future.
The IDS, developed by Annis and Davis (1989), offers a systematic way of evaluating relapse risk that can be helpful in treatment planning. The IDS is a de tailed assessment instrument that deter mines clients' specific highrisk situations and provides profiles of typical situations that are likely to pose problems. Annis and Davis also emphasize the importance of assessing clients' strengths and avail able resources, in addition to risks, to determine the most appropriate starting point for a skills training program.

BEHAVIORAL MARITAL AND FAMILY THERAPY
Family members seem to be well posi tioned to support a client's recovery process. They may, however, have little knowledge about alcohol dependence, may be misinformed about how to respond to their loved one's condition, and may have developed troublesome behavior patterns of their own that could sabotage the client's recovery. Family members gener ally require education about alcohol and its effects as well as opportunities to discuss the impact that a loved one's alcoholism has had on their lives.
Coping skills training approaches have been developed for alcoholic couples (i.e., behavioral marital therapy; O'Farrell and Cutter 1984) and have been broadened for use with other family members as well (O'Farrell and Cowles 1989

COMMUNITY REINFORCEMENT
This treatment approach incorporates various behavioral procedures into a comprehensive intervention package, with special emphasis on clients' making use of communitybased supports (Sisson and Azrin 1989). Its chief goal is to develop a highly reinforcing sober lifestyle that clients will seek to perpetuate, thus ad dressing not only the drinking problem but also the negative lifestyle factors likely to undermine recovery. With such a positive lifestyle in place, drinking likely will be avoided, because it would result in the withdrawal of valued social supports and reinforcers. This approach thus may be considered a form of contingency management (discussed above).
The community reinforcement ap proach combines several interventions. Recognizing the powerful role of social contingencies in the recovery process, this approach provides social skills training; a "buddy," whose role is to support the client's efforts at maintaining sobriety; counseling regarding leisure and recre ational activities; and an alcoholfree social club that sponsors activities and provides a safe place for clients to "hang out." Unemployed clients are referred to a supportive "job club," where they can organize their résumés, learn about job leads, and practice interview techniques. Clients also are taught strategies for coping with urges to drink and refusing offers to drink. They are encouraged to take disulfiram (Antabuse ® ) as a deterrent to drinking and to identify a significant other who will support them in taking the medication each day. Finally, clients are offered behavioral marital counseling as a means of reducing stress at home, im proving communications within the fami ly, and enhancing support for sobriety.
Provision of this wide range of services requires that several specialized program elements be in place and necessitates considerable organization on the part of treatment staff to ensure that each client receives a coordinated package of services that will meet his or her particular needs.

BEHAVIORAL SELFCONTROL TRAINING
This variant of the cognitivebehavioral approach focuses on what clients can do to modify their own behavior. It includes identifying drinking situations, setting goals, monitoring oneself, learning and practicing coping skills, and rewarding oneself for accomplishing goals . Clients can receive guidance from a therapist or through the use of a selfhelp manual. In either case, the client assumes responsibility for determining the content and pace of treatment. Selfcontrol training may have a goal of total abstinence, but more often it uses a goal of "controlled drinking" for clients who have shorter durations of problem drinking and relatively few alcoholrelated problems. This goal is not used for heavily dependent drinkers.

AVERSION THERAPY
This approach seeks to develop a condi tioned aversion in the client by associ ating an aversive event with alcohol. Treatment involves either pairing stressful or painful stimuli (e.g., nausea or electric shock) with actual alcohol consumption or pairing images of drinking with images of unpleasant scenes or experiences. Effectiveness of the procedures is en hanced when they are combined with other cognitivebehavioral strategies (Rimmele et al. 1989). Aversion therapies have been implemented in only a few treatment centers and have not been adopted widely by treatment providers.

CUE EXPOSURE THERAPY
Cue exposure therapy seeks to diminish a client's responsiveness to antecedent factors that lead to drinking (Cooney et al. 1983). It involves repeatedly presenting a client's favorite alcoholic beverage, en couraging the client to observe and smell the drink, but not allowing the client to consume any of it. The arousal generated in this situation may be heightened by having the client simultaneously imagine an emotional scene in which he or she would be likely to drink. The repeated exposures to alcohol, without the re inforcement of actual drinking, may re duce its power either to elicit cravings or to signal an opportunity to drink. This treatment also may provide an opportuni ty to practice coping skills in the presence of alcohol (Monti et al. 1989). Cue expo sure therapy is still in the experimental stage, with support for its efficacy thus far coming mainly from case reports (Insti tute of Medicine 1990).

MOTIVATIONAL INTERVIEWING
Although not strictly a cognitivebehavioral approach, this technique is included here because it incorporates behavioral proce dures, such as shaping and reinforcing clients' statements about the need for change, and has as a goal the development of strategies for changing behavior.
Poor motivation for change is an ageold problem, particularly in the field of alcoholism treatment, where clients' ambivalence has led to a troublesome lack of treatment compliance. Recently, a systematic approach called motivational interviewing has been developed to en hance client motivation. It is based on principles of cognitive therapy and the clientcentered approach developed by the psychologist Carl Rogers (Miller and Rollnick 1991). Its goal is to help clients resolve their ambivalence and reach a commitment to change.
Motivational interviewing starts with the therapist recognizing and accepting client ambivalence. Proceeding through what may be characterized as a gradual shaping process, the therapist tries to move the client toward acknowledging current problems, developing a desire to change them, and identifying strategies that will enable this change.
The therapist first discusses problems that the client has perceived or concerns that others have voiced, providing em pathic feedback, which communicates an understanding and acceptance of the client. These interventions attempt to establish a climate in which the client feels safe enough to identify and explore areas of dissatisfaction with his or her life. Using this process, the therapist avoids arguing with the client, confront ing the client's resistance head on, or labeling the client as an alcoholic. The therapist instead assumes a reflective attitude to allow exploration of both sides of the client's ambivalence without undu ly arousing defensiveness. Throughout the course of the discussion, the therapist provides frequent summaries of what the client has said to focus attention on the problems that are being uncovered and to

PATIENTTREATMENT MATCHING FINDINGS
To date, treatment outcome research has failed to identify any single ap proach that is superior across the varied spectrum of alcoholic clients. As a result, the alcoholism treatment field is looking increasingly to patient treatment matching research to identi fy treatment approaches that will provide the most benefit to subgroups of clients with particular needs (for a more detailed review of patient treatment matching, see the article by Mattson,. The patienttreatment matching literature is still in its infancy, with relatively few empirical studies. Nevertheless, some reports identify client characteristics indicating which clients could benefit most from what cognitivebehavioral and behavioral approaches. In one such series of reports, colleagues (1989, 1992;Cooney et al. 1991) found that clients who had more sociopathic characteristics, more evidence of psychopathology, and a greater urge to drink (in a roleplay situation) were more likely to remain abstinent and less likely to suffer renewed alcohol related problems if they were given coping skills therapy in group treat ment. (Some of these findings were replicated by Longabaugh et al. 1994.) Clients who were relatively free of these characteristics at the beginning of treatment fared better if they were assigned to interactional group thera py, a therapy that fosters insight and healthier interpersonal functioning in patients by developing a group that encourages selfdisclosure and free expression of emotions.
Findings from other matching studies that employed cognitive behavioral treatments (see review by Matt son et al. 1994) indicated the following: • Clients with an external locus of control (i.e., those who believe that the course of their lives is determined by external forces) experience better outcomes with coping skills counseling.
• Clients who are less educated, have substantial urges to drink, or experi ence high anxiety benefit most from communication skills training.
• Clients who can identify specific highrisk situations do better with relapse prevention treatment.
• Single men benefit most from the community reinforcement approach.
• Clients with poor motivation benefit more from motivational interviewing than from skillsbased counseling.
The emerging literature has thus iden tified several client characteristics that potentially could serve as the basis for matching clients to cognitivebehavioral treatments, but more work is needed to determine their practicality in clinical settings. The National Institute on Alcohol Abuse and Alcoholism is sponsoring an ongoing multisite cooperative study (Project MATCH Research Group 1993) that will have sufficient participants to test numerous hypotheses for matching clients to cognitivebehavioral treatment as well as to 12step and motivational enhance ment treatments. It is anticipated that the matching strategy will enhance the effec tiveness of all treatments, including the behavioral ones, by directing their appli cation to the clients who are most likely to benefit from them.
-Ronald M. Kadden highlight whatever motivational state ments the client has made along the way. Through a gradual application of this process, the client is made increasingly aware of problems that he or she may have been ignoring; through this aware ness, the client is brought to the point of accepting the need for change and then to formulating a strategy for making behav ior changes. Subsequent checkup visits may be used to maintain the client's motivation and to determine whether the client has followed through with agreed upon change strategies.

EFFECTIVENESS OF COGNITIVE BEHAVIORAL APPROACHES
Cognitivebehavioral approaches to alco holism were developed from behavior change principles that have been applied to a wide range of disorders, and their application to alcohol problems has been guided by empirical research findings (George and Marlatt 1983;Abrams and Niaura 1987). Such findings support the effectiveness of these treatments in ad dressing several problems that alcoholics typically confront as they seek to recover (e.g., coping with highrisk situations).
In addition, other considerations sup port the use of cognitivebehavioral treat ment methods for alcoholic clients, specifi cally in the early stages of their recovery from alcohol dependence. Even after they have completed detoxification, for exam ple, clients may experience persistent cognitive impairment, such as faulty mem ory, from the effects of alcohol. The im pairment often coincides with the time during which treatment is given. In view of such impairment, it has been suggested (e.g., Goldman 1987) that clients would benefit from a structured treatment ap proach, such as one of those reviewed here, that breaks learning tasks into small, easily mastered units and provides repeat ed practice and review of new skills to enhance retention (although not all re search supports this recommendation).
Another consideration is put forward by some advocates of dynamically oriented therapies that seek to develop clients' insight through the exploration of conflicts and other sources of emotional distress. There is concern that the discomfort typi cally associated with uncovering long standing psychological problems and emotional material may increase the proba bility of relapse and therefore should be avoided in the early stages of recovery (Zweben 1986). An intervention that focuses on concrete tasks (as cognitive behavioral approaches do), rather than on exploring emotional matters, avoids this problem and may be the treatment of choice for many clients early in recovery.

Results of Treatment Outcome Studies
In a comprehensive review of research on alcoholism treatment outcome, Miller and Hester (1986) identified social skills training, stress management, and the community reinforcement approach as receiving sound support from controlled studies that have been replicated. The clients who benefited most from these approaches had skills deficits in areas specifically addressed by the treatment they received. Another review of alco holism treatment effectiveness, conducted by the Institute of Medicine (1990), cited social skills training, marital and family therapy, stress management training, and the community reinforcement approach as showing "promise for promoting and prolonging sobriety" (p. 538). The same report also noted that behavioral self control training appears effective for clients who are not severely alcohol dependent. Two of the interventions described above have not yet been widely used or extensively tested, although promising outcomes have been reported. Studies of motivational interviewing, which is a relatively new technique, have provided early indications of effectiveness (Bien et al. 1993). Cue exposure therapy is still in the experimental stages and is not ready for widespread clinical application.

CostEffectiveness
Cognitivebehavioral treatments have scientific origins and have maintained a tradition of empirical validation of clini cal procedures. This scientific examina tion of treatment techniques may turn out to be an important advantage in the emerging climate wherein thirdparty payers scrutinize treatment outcome and costeffectiveness. In a review of the effectiveness and costeffectiveness of various treatments for alcoholism (Holder et al. 1991), those treatments with the best evidence of effectiveness were cognitive behavioral and behavioral approaches, including social skills training, selfcontrol training, behavioral marital therapy, the community reinforcement approach, stress management, and motivational interview ing. These also were rated as the most costeffective, falling in a range from minimal to mediumlow on a scale of costliness. Aversion therapies, on the other hand, showed either fair evidence of effec tiveness (when using imagined aversive scenes) or no evidence of effectiveness (when using electric shock or nausea).

SUMMARY
In a cognitivebehavioral conceptualiza tion of alcohol dependence, drinking is regarded as a learned behavior that can be altered by identifying its antecedents and consequences and by modifying the drinker's responses to them. The treatment approaches described in this article are modeled in a variety of ways on this basic precept. With the possible exceptions of aversion therapy and cue exposure thera py, these various approaches have been found to be both effective and cost effective. However, because no single approach has been found effective for most alcoholics, patienttreatment match ing (see sidebar) has received increased attention as a way of improving treatment effectiveness. ■

ACKNOWLEDGMENT
The author expresses thanks to Ned Cooney, Ph.D., for his helpful comments on this paper.